Diabetic Ketoacidosis

Pickering 1 Leticia Pickering Nutrition 302 Dr. Michael Zemel 7 March 2008 Ketoacidosis in the Type I Diabetic Patient Type I diabetes, or insulin-dependent diabetes, is a disease that causes many complications in various systems throughout the body. One of these is diabetic ketoacidosis (DKA), a condition caused by the build up of toxic ketone bodies as a result of impaired disposal mechanisms (1). This disease is characterized by high blood glucose, dry mouth, excessive thirst, and a sweet, fruity smell on the breath, a symptom indicative of the presence of ketone bodies (2). There are many factors that cause diabetic ketoacidosis in the type I diabetic patient, but four causes stand out as the most prevalent: insulin deficiency, stress hormone excess, fasting, and dehydration (1). Prevention and treatments of this toxic condition have become increasingly more effective and accessible in the past couple of decades. Once thought to be a death sentence, diabetic ketoacidosis is now more easily recognized and treated before significant damage can be sustained. Once thought to be the main cause of diabetic ketoacidosis, the increased availability of supplemental insulin, along with increased awareness of other contributing factors has lowered this assumption (1). In the context of ketoacidosis, relative insulin deficiency is defined as “a plasma insulin concentration between 6 uU/ml and 50 uU/ml when the plasma glucose concentration exceeds 250 mg/dl” (1). A lack of insulin in hyperglycemic conditions leads to reduced capability of the body to effectively metabolize lipids, leading to the formation of toxic ketone bodies. Although the body is

Pickering 2 equipped with mechanisms known as organic alkalis to remove toxins from the body, an excess of toxins surpasses their ability to neutralize the acidic environment, allowing the ketones to accumulate in the blood stream (2). Poor insulin compensation is usually due to a lack of education and general ignorance as to the serious consequences it may have. For this reason DKA is most often observed in children and newly diagnosed adults who lack the experience to recognize the characteristic symptoms. Another area of diabetes management that is often difficult to master and which can also influence the development of ketoacidosis is consistency of the diet. Hypoglycemia, or low blood glucose levels, can negatively effect the progression of ketoacidosis. A properly balanced diet consisting of an appropriate fat to carbohydrate ratio utilizes approximately one unit of fat to every two units of carbohydrates. Deviation from this balance will interfere with lipolysis, the decomposition of fat molecules. “When sufficient glucose is not being burned there is excessive and abnormal oxidation of fat, and instead of carbonic acid there is a production of toxic ketone substances” (4). Fasting, used in the context of DKA to describe an inconsistent eating pattern in a diabetic patient, is often secondary reaction to the “nausea, vomiting, and abdominal pain which accompany the ketoacidotic state” (1). Another dietary matter that is an integral part of the development of DKA is that of dehydration. Dehydration, much like fasting and hypoglycemia, is often a secondary reaction to the development of DKA as a result of nausea, vomiting and diarrhea. It is easy to recognize dehydration by observation of unusually dry mucous membranes, dry skin, loss of firmness in the skin and elevated heart rate (1). Dehydration and a general deficiency of fluid in the system only serve to exacerbate the condition as a lack of fluid in the body

Pickering 3 prevents the renal system, namely the kidneys, from functioning properly, which consequently leads to an inefficient “excretion of large quantities of glucose and ketone bodies” (4). Water allows important bodily functions to be carried out and so rehydration must be a priority in treatment. The condition can be difficult to treat because ketoacidotic patients usually experience extreme nausea, vomiting and diarrhea which decrease their tolerance of the food and beverages that would normally help to restore appropriate fluid levels. For this reason, immediate hospitalization is required so that emergency intravenous fluids can be administered. The cause of dehydration, along with insulin deficiency and hypoglycemia can be explained by a common factor: an excess of stress hormones. Stress, whether it originates from internal or external sources is a large factor in the development of diabetic ketoacidosis. Although the other causes are serious, they rarely occur independently of an excess of stress hormones. As more research is done in the field of ketoacidosis, it is increasingly well established that there is a positive correlation between its development and stress hormone secretion. One study found that after a stimulus, the fever inducing drug pyrogen, was purposefully administered on a test subject to determine the effects of stress on the development of ketoacidosis, surprising results were observed. The stress hormone groups, including catecholamines, cortisol, growth hormone, and glucagon, were all secreted in response to the internal stress causing an increase in plasma glucose and ketone bodies. Despite frequent insulin injections in an attempt to stabilize those levels, they maintained high levels which indicated the role that stress hormone secretion played in initiating ketoacidosis (1). This observation makes sense, especially considering the role that glucagon has in regulating

Pickering 4 the concentration of ketone bodies. Glucagon is primarily responsible for regulating the production of glucose through a process called gluconeogenesis and for regulating the rate of lipolysis. An increase in glucagon, such as occurs when a stress is introduced to the body, results in an increase in the rate of lipolysis. This increase in lipid decomposition “leads to a higher concentration of free fatty acids which leads to higher ketone concentration” (5). Effective treatment of diabetic ketoacidosis is a multi step process that requires the expertise of specialized medical professionals. The first issue that must be treated is dehydration. This takes priority because once fluid and electrolyte balance is restored the body will have the water that is essential for its metabolic processes. Rapid volume expansion is followed by a period of slow volume expansion to reduce the occurrence of cerebral edema, or swelling of the brain (3). As previously mentioned, many patients suffering dehydration as a side effect of ketoacidosis also experience nausea, vomiting and diarrhea. These patients should have their fluids administered intravenously to improve absorption rates. Although the first priority in treatment is to restore fluid balance to the patient, the other causes of DKA must also be addressed before a full recovery can be made. One method of insulin control is an experimental treatment known as Diabetes Treatment and Teaching Programs (DTTPs). This method’s effectiveness was tested in laboratory research experiment that was recently published in Diabetes Care. DTTP is a program that focuses on education on proper insulin dosage and administration to control blood glucose levels. Subjects were individuals with type I diabetes who experienced at least three occurrences of ketoacidosis over the course of a year, which qualified them as

Pickering 5 being at high risk for severe ketoacidosis. As the first step in the procedure, the subjects underwent a “five day structured in patient course for intensive insulin therapy” (6). This therapy focused on teaching the diabetic patient how to more accurately calculate the appropriate dose of insulin in correspondence to the foods that they eat. The results for this experiment indicated that patients that DTTP is in fact a beneficial method of controlling insulin levels and preventing ketoacidosis. “Seventy two percent of participants had no recurrent severe ketoacidosis the year after intervention”, which seemed to also decrease the incidence of hypoglycemia in the long term (6). Diabetic ketoacidosis is one of the most devastating complications of diabetes, as it has many toxic effects on the body. Although research in recent years has produced significant advances in the prognosis and treatment of ketoacidosis, it is a disease that should be treated with urgency and, due to its volatile nature, should only be treated by a medical team with extensive experience in specifically treating diabetic patients. Although prevention is the best method of treatment, it is important for the diabetic patient to know and recognize the symptoms of acidosis so that, in the event of its development, they can seek prompt treatment.